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Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa
  1. Cyrill Meuwly1,2,
  2. Gregor Leibundgut2,3,
  3. Thomas Rosemann4,5,
  4. Bernhard Schaller5
  1. 1Department of Anaesthesia, Kantonsspital Baselland, Liestal, Switzerland
  2. 2Faculty of Medicine, University of Basel, Basel, Switzerland
  3. 3Department of Cardiology, Kantonsspital Baselland, Liestal, Switzerland
  4. 4Department of Primary Care, University Hospital of Zürich, Zürich, Switzerland
  5. 5Faculty of Medicine, University of Zurich, Zurich, Switzerland
  1. Correspondence to Dr Cyrill Meuwly, cyrill.meuwly{at}


The trigeminocardiac reflex (TCR) is defined as a sudden onset of parasympathetic dysrhythmias during stimulation of the trigeminal nerve. We describe a peripheral variation of TCR during manipulation of the nasal mucosa. A 42-year-old patient suffering from severe obstructive sleep apnoea was scheduled for surgical treatment. After inducted anaesthesia, the surgeon infiltrated the nasal mucosa with a local anaesthetic. The patient immediately showed an asystole and was treated with ephedrine and five chest compressions, despite spontaneous sinus rhythm return after ceasing of manipulation. Treatment with atropine established this TCR episode and ensured an event-free surgery.

The authors present here, for the first time, a prolonged asystole caused by the TCR, triggered by minimal manipulation of the nasal mucosa. This severe manifestation of peripheral TCR demonstrates its importance in daily clinical business. This case was treated according to a modified treatment algorithm for all subtypes of TCR which is presented here.

  • anaesthesia
  • cardiovascular medicine
  • arrhythmias
  • ear, nose and throat/otolaryngology
  • cranial nerves

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  • Contributors CM: contributed planning, conception, data analysis and a proof of the manuscript. GL: contributed main input in discussion and interpretation of data. TR: helped interpreting the case report. BS: supervised the working process and supported the first author in planning and conception; finalised the discussion.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.